The Cost Effectiveness of Implementation of a Postoperative Endocrinopathy Management Protocol after Resection of Pituitary Adenomas

Abstract

Purpose After developing a protocol for evaluating, diagnosing, and treating postoperative endocrinopathy both during the hospitalization and during the immediate discharge period following resection of pituitary adenomas, we sought to assess the impact of this protocol on quality outcomes. Methods An IRB-exempt, quality improvement initiated, Health Insurance Portability and Accountability Act (HIPAA)-compliant retrospective comparison of a pre-and-post-protocol cohort of all patients undergoing endoscopic endonasal resection of pituitary adenomas at NYU Langone Medical Center from January 2013 to December 2018. Demographic characteristics of the patients and their tumors with their postoperative outcomes were recorded. Quality outcomes regarding number of laboratory studies sent, rate of diabetes insipidus, length of stay, and readmission rate were also recorded. Statistical analysis was performed between the pre- and post-protocol groups. Results There was a significant reduction in laboratory studies sent per patient (55.66 vs. 18.82, p <0.001). This corresponded with an overall cost reduction in laboratory studies of $255.95 per patient. There was a decrease in the overall number of patients treated with DDAVP (21.4% in the pre-protocol group vs. 8.9% in the post-protocol group, p = 0.04). All post-protocol patients requiring DDAVP at discharge were identified by 48 hours. There was no significant change in length of stay or need for hydrocortisone supplementation postoperatively between the two groups. Length of stay was driven mostly by need for reoperation during initial hospitalization. There was no significant change in the rate of 30-day readmission. Conclusion Implementation of a postoperative management protocol results in a more efficient diagnosis and management of endocrinopathy after pituitary adenoma surgery which translates to decreased cost.

Diabetes Insipidus after Endoscopic Endonasal Pituitary Macroadenoma Resection: Correlation of Patient and Surgery-Related Risk Factors

“…Among the 171 patients included in the study, 31 developed DI and received desmopressin, which increased the LOS to 7.39 days in comparison to 4.36 days for the remaining 140 patients (p < 0.0001). 19 The results of this investigation highlight the role of patient-and surgery-related factors, namely, intraoperative CSF leak, nasal packing, and multilayered reconstruction in predicting the development of CDI following EEPS. Nevertheless, this study has its limitations.…”

Multidisciplinary Team Care in Pituitary Tumours

“…On the other hand, Pituitary MDT for healthcare professionals may be beneficial for professional fulfillment, and may result in closer relationships between different specialists and the development of new skills, knowledge, and learning opportunities while providing some medico-legal protection [ 3 ]. Although substantive evidence is still limited, few studies comparing the outcomes of patients treated before and after the implementation of Pituitary MDT ( Table 2 ) highlight some of the benefits [ 2 , 36 , 37 ].…”

“…Pituitary MDT benefits have also been highlighted in a series of four women with sellar lesions during pregnancy [ 41 ]. Benjamin et al assessed the cost effectiveness of a post-operative protocol after resection of pituitary tumours implemented by their MDT, concluding that there was a significant cost reduction in laboratory studies (of USD 255.95 per patient); there was also a decrease in the number of patients treated with desmopressin post-operatively after the protocol implementation [ 36 ]. Such MDT-based protocols may reduce hospital stays and readmissions, and improve the outcomes and safety of surgical patients [ 36 , 37 , 42 , 43 ].…”

“…While such direct costs are easier to calculate based on the time spent and number of physicians involved in such meetings, the indirect financial benefits and cost-effectiveness for high-quality decision making and more efficacious management of pituitary tumours are more difficult to assess, and remain poorly described [ 2 , 110 ]. Recent studies showed that the creation of a Pituitary MDT reduced inpatient hospital days [ 2 , 37 ], decreased post-operative complications [ 2 , 40 ], lowered the risk of readmission after surgery [ 39 ], and reduced costs in laboratory studies [ 36 ], while at the same time improving clinical outcomes [ 36 , 37 , 42 , 43 ]. Multidisciplinary management of patients with functioning tumours achieves higher rates of biochemical cure [ 51 , 53 , 54 , 55 , 56 , 57 , 58 , 59 ], allowing significant savings in terms of their long-term management associated with the costs of medications to treat hormone excess in persistent or recurrent disease.…”

“…On the other hand, Pituitary MDT for healthcare professionals may be beneficial for professional fulfillment, and may result in closer relationships between different specialists and the development of new skills, knowledge, and learning opportunities while providing some medico-legal protection [3]. Although substantive evidence is still limited, few studies comparing the outcomes of patients treated before and after the implementation of Pituitary MDT (Table 2) highlight some of the benefits [2,36,37]. • Transient DI and SIADH, as well as new secondary hypothyroidism, occurred less often post-MDT (20 vs. 36%, p < 0.01; 18 vs. 39%, p < 0.01; and 5 vs. 15%, p < 0.01, respectively) • Hospital stay was shorter post-MDT (5 vs. 7 days, p < 0.001) • Intrasellar residues were less common post-MDT (8 vs. 35%, p< 0.001) • Peri-and post-operative complications were more frequent pre-MDT (41 vs. 69%, p < 0.001), and were independent of tumour size, hormone status, and surgical technique (OR = 2.14 [1.05-4.32], p = 0.04).…”